Provider Demographics
NPI:1932549979
Name:HANLEY, MELANIE S (PA-C)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:S
Last Name:HANLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:S
Other - Last Name:BOUTHILLIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:CO
Mailing Address - Zip Code:81425-0529
Mailing Address - Country:US
Mailing Address - Phone:970-323-6141
Mailing Address - Fax:970-323-6117
Practice Address - Street 1:1250 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-3138
Practice Address - Country:US
Practice Address - Phone:970-874-8981
Practice Address - Fax:855-299-7586
Is Sole Proprietor?:No
Enumeration Date:2013-07-03
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54730091Medicaid
COP01664176OtherRAILROAD WORKERS MEDICARE PTAN FOR RIVER VALLEY FAMILY HEALTH CENTER
CO502998YS6EOtherMEDICARE B FOR RIVER VALLEY FAMILY HEALTH CENTER